NUR 3227C Exam #2

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which type of care will now be removed from the treatment plan? SATA. A. chemotherapy B. repositioning C. regular oral care D. blood transfusion E. radiation therapy

A, D, E

Which reason will the nurse include when explaining why insulin should be stored at room temperature? A. its potency and effectiveness are maximized B. absorption is enhanced and local irritation is decreased C. it is more convenient and drawing insulin into the syringe is facilitated D. adherence of insulin to the syringe and resistance upon injection are decreased

B. absorption is enhanced and local irritation is decreased

The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education? A. "I should see whether the insulin is expired." B. "I should keep a diary logbook of times of insulin injection." C. "I should keep my medication in its original labeled container." D. "I should administer insulin only if there are any symptoms."

D. "I should administer insulin only if there are any symptoms."

Which strategies would the nurse use to reduce pain during or after vaccination in a child? SATA. A. applying topical anesthetic B. providing tactile stimulation C. holding the child upright during vaccination D. performing intramuscular injections rapidly with prior aspiration E. administering analgesics or antipyretics such as acetaminophen to reduce pain

A, B, C

Which action is appropriate for the registered nurse regarding assisted suicide? A. nurses may have an open attitude toward the client's end of life B. nurses' participation in assisted suicide violates the code of ethics C. nurses may listen to the client's expressions of fear and attempt to control the client's pain D. nurses can participate in assisted suicide only if the individual could make an oral and written request

B. nurses' participation in assisted suicide violates the code of ethics

A client suffering from cancer is near the end of life. Which action(s) would be performed by the nurse to support the client's family members? SATA. A. helping the family set up hospice B. taking time to make sure that the family understands care options C. staying with the client in the absence of family members D. giving the family information about the dying process E. making sure that the family knows what to do at the time of death

A, B, C, D, E

A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? A. the local hazardous waste collection site B. the regular household trash C. the local health department for disposal D. the Environmental Protection Agency (EPA) through the mail

A. the local hazardous waste collection site

Which concept of death would the nurse expect a 4-year-old child to have? A. cessation of life B. reversible separation C. only affects old people D. force takes one away from family

B. reversible separation

Which statements made by a terminally ill client address primary goals regarding end-of-life (EOL) nursing care? SATA. A. 'I want my children and my grandchildren to carry my casket.' B. 'I've prepaid all my funeral costs so there's no burden on my family.' C. 'My living will states that I want no heroic measures to prolong life.' D. 'Pain is a concern, so I've discussed that thoroughly with my doctor.' E. 'I've made arrangements to spend my final days in my own home.'

C, D, E

The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select? A. levin B. dobhoff C. salem sump D. gastrostomy

C. salem sump

The registered nurse (RN) is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a health care setting. Which statement made by the nursing student indicates the need for further teaching? A. 'I would check the new medication prescription against the current list of medicines.' B. 'I would avoid asking about the client's over-the-counter medications.' C. 'I would obtain a comprehensive and current list of the client's medications.' D. 'I would avoid distractions and go slowly when reconciling the client's medications.'

B. 'I would avoid asking about the client's over-the-counter medications.'

The nurse is providing care to a client who is receiving enteral feedings via a nasogastric (NG) tube. Which serious complication would the nurse take measures to prevent? A. skin breakdown B. aspiration pneumonia C. retention ileus D. profuse diarrhea

B. aspiration pneumonia

Which action would the nurse take first when preparing to teach a client about self-injection of epoetin subcutaneously at home? A. demonstrate the injection technique B. assess the client's readiness to learn C. explain how to perform sterile technique D. schedule follow-up by a home health nurse

B. assess the client's readiness to learn

Which angle would an obese client be taught to self-administer an insulin injection at? A. 30-degree angle B. 60-degree angle C. 45-degree angle D. 90-degree angle

D. 90-degree angle

Which information must be clearly described in the medication administration record (MAR) before administering a medication? SATA. A. dosage and route B. client's full name C. time to be administered D. frequency of administration E. full name of prescribed medication

A, B, C, D, E

Which instruction would the nurse provide to a 6'0", 160-pound client newly diagnosed with type 1 diabetes who wants to self-administer injections with an insulin pen? SATA. A. prime the needle with two units B. use a 29-gauge insulin needle C. give the injection at 45-degree angle D. refrain from recapping the needle E. dial the pen to deliver the unit dose

A, B, C, D, E

Which problems would the nurse plan to address when dealing with ethical issues specifically related to end-of-life care? SATA. A. clients may be unable to communicate effectively B. all interventions for helping the clients seem futile C. clients are often unfamiliar with the concept of autonomy D. multiple medications affect the cognitive ability of the clients E. predictions regarding health outcomes are not always accurate

A, B, E

The nurse is preparing to administer an ophthalmic medication to a client. Which steps would the nurse include for this procedure? SATA. A. clean the eyelid and eyelashes B. place the dropper against the eyelid C. apply clean gloves before beginning the procedure D. instill the solution directly onto the cornea E. press on the nasolacrimal duct after instilling the solution

A, C, E

An older client asks, 'How do I know that the medications that I take are safe?' Which response by the nurse is correct? SATA. A. 'Ask your health care provider how and when you should be taking your medications.' B. 'Stop taking a prescribed medication if you are not feeling better in a few days.' C. 'Discard medications into the toilet that have excessed the expiration date on the bottle.' D. 'Check the name, dose, and instructions about administration of medications each time before leaving the pharmacy.' E. 'Inform your health care provider of the over-the-counter medications, recreational drugs, and amount of alcohol you ingest.'

A, D, E

The student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse (RN)? A. 'Palliative care is the same as hospice care.' B. 'Palliative care focuses on the care of the client.' C. 'Palliative care includes symptom management in the client.' D. 'Palliative care is an interprofessional approach to the delivery of care.'

A. 'Palliative care is the same as hospice care.'

Which is the most important nursing action involved in caring for a client receiving medications? A. administering the medications B. teaching about the medications C. ensuring adherence to the medication regimen D. evaluating the client's ability to self-administer medications

A. administering the medications

A health care provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. Place the nursing interventions in the order in which they should be implemented. A. elevate the head of the bed to at least 30 degrees B. verify the health care provider's prescription C. administer the volume of feeding as per the prescription D. flush the tube with 30 mL of water after the feeding E. check the volume of residual against the parameters prescribed

B, A, E, C, D

Place the following nursing statement reflecting Kubler-Ross' five stages of dying/grief in the correct order. A. "Have you and your oncologist talked about how radiation therapy might prolong your life?" B. "You do understand that your child experienced a fatal head trauma in the accident?" C. "Being angry at your partner for dying and leaving you alone is a natural grief reaction." D. "I've collected the information you requested concerning end-of-life planning." E. "Can we talk about the benefits of agreeing to take an antidepressant medication?"

B, C, A, E, D

The nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. A. instill the prescribed solution B. monitor the client's output on a regular basis C. verify the solution to be administered D. document the client's response to the procedure E. aspirate the contents of the stomach

C, E, A, D, B

Which response would the nurse give when a client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" A. "Let me ask your health care provider for you." B. "No one knows the answer to that question." C. "Tell me about what concerns you right now." D. "It depends on how extensive the disease is."

C. "Tell me about what concerns you right now."

The nurse provides education to a client who is learning how to self-administer gastrostomy tube feedings and would include which instruction? A. administering water after the feeding is completed B. maintaining the supine position during the feeding C. heating the feeding solution to slightly above body temperature D. determining tube placement by instilling water before the feeding

A. administering water after the feeding is completed

Which action would the nurse take after the medication has been injected and the needle withdrawn when administering an intradermal tuberculosis skin test to a client? A. place a piece of gauze over the injection site B. scrub the site with povidone-iodine solution C. vigorously wipe the area with an alcohol wipe D. circle the area with a skin pen

A. place a piece of gauze over the injection site

Which would the nurse emphasize when teaching insulin self-administration to a child with recently diagnosed diabetes? A. the need to wash the hands before preparing the insulin injection B. the need to shake the bottle of insulin thoroughly before drawing up the dose C. the need to alternate the sites of the insulin injections among the four extremities D. the need to rub the injection site briskly for half a minute after giving the injection

A. the need to wash the hands before preparing the insulin injection

A client arrives at a health clinic reports, "I am here to have my tuberculin skin test read." The nurse notes a 7-mm indurated area at the injection site. Which nurse's statement describes this result. A. "The result indicates that you have active tuberculosis." B. "The result indicates you are infected with the tuberculosis organism." C. "The result indicates there are no tuberculin antibodies in your system." D. "The result indicates you have a secondary infection related to the tuberculin organism."

B. "The result indicates you are infected with the tuberculosis organism."

Which is the maximum volume of an intramuscular injection recommended for a preschool-aged child? A. 0.5 mL B. 1.0 mL C. 1.5 mL D. 2.0 mL

B. 1.0 mL

Which measure would the nurse take when administering enoxaparin subcutaneously? A. push over 2 minutes B. administer in the abdomen C. massage site after administration D. remove air pocket from prepackaged syringe before administration

B. administer in the abdomen

Which process would the nurse use to determine the length of tube needed to reach a client's stomach for nasogastric feeding? A. the tube is advanced until resistance is met B. the tube is advanced until gastric contents are aspirated C. a measurement is made from nose to earlobe and then to the epigastric area D. a measurement is made from mouth to umbilicus and then half that distance is added

C. a measurement is made from nose to earlobe and then to the epigastric area

The nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun to care for the client. Which is the best nursing intervention in preparing for the client's discharge? A. contact the client's health care provider to ask to substitute a liquid form of medications for the pill form B. teach the client and family members to crush the pills and administer them with applesauce C. contact the client's health care provider to discuss use of transdermal medications for pain control D. teach the client and family members about addiction that may occur as a result of regular opioid use

C. contact the client's health care provider to discuss use of transdermal medications for pain control

Which action would the nurse take when administering iron dextran? A. use a transdermal needle B. massage the injection site C. use the Z-track method D. apply a local anesthetic first

C. use the Z-track method

A client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic and trembling. Which intervention is appropriate? A. administer insulin to the client B. give the client lunch immediately C. encourage the client to drink fluids D. assess the client's blood glucose level

D. assess the client's blood glucose level

Which nursing intervention would be the priority for a client in hospice care with symptoms of dyspnea? A. administer benzodiazepines B. apply wet cloths on the client's face C. encourage imagery and deep breathing D. provide prescribed oxygen by nasal cannula

D. provide prescribed oxygen by nasal cannula

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. Which explanation would the nurse give for why a PEG tube is preferred for administering a tube feeding? A. there is less chance of aspiration with a PEG tube B. the PEG tube does not require a pump C. self-administration of the tube feeding is possible D. more tube feeding mixture can be given each time

A. there is less chance of aspiration with a PEG tube

The nurse realizes that a double dose of insulin was administered to the client by mistake and informs the primary health care provider. Which element of the decision-making process is reflected in the nurse's action? A. authority B. autonomy C. accountability D. responsibility

C. accountability

A client is receiving intermittent nasogastric (NG) tube feedings to supplement oral nutritional intake. The nurse administers the feeding over 30 to 60 minutes to reduce which hazard? A. distention B. flatulence C. indigestion D. regurgitation

D. regurgitation

The nurse is teaching a student nurse about how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding. Which information would the nurse include? SATA. A. keep the head of the client's bed elevated at least 10 degrees B. connect the tube feeding bag to the client and feeding pump C. flush with warm water before feeding D. check the prescription for the correct formula E. set the correct rate and initiate the pump F. check for diarrhea

B, C, D, E, F

While preparing to teach a client about self-injection of insulin, which nurse's action would increase the effectiveness of the teaching session? A. wait until a family member is also present B. assess the client's barriers to learning self-injection techniques C. begin with simple written instructions describing the technique D. wait until the client has accepted the new diagnosis of type 1 diabetes mellitus

B. assess the client's barriers to learning self-injection techniques

Which technique will the nurse employ to prevent excessive bruising when administering subcutaneous heparin? A. administer the injection via the Z-track technique B. avoid massaging the injection site after the injection C. use 2 mL of sterile normal saline to dilute the heparin D. inject the medication into the vastus lateralis muscle in the thigh

B. avoid massaging the injection site after the injection

According to the nursing process, which action would the nurse take after administering pain medication to a postoperative client? A. administer non pharmacological comfort measures B. inform the health care provider of the nursing action C. create a care plan that addresses the client's pain level D. determine whether the pain medicine relieved the client's pain

D. determine whether the pain medicine relieved the client's pain

A client with dementia is discharged home with a percutaneous endoscopic gastrostomy (PEG) tube in place. A family members receives instructions about how to care for the tube. Which action observed by the home health nurse indicates that the family member is effectively managing the client's care? A. keeps the empty feeding bag attached to the tubing B. flushes the tube with air after medication is given C. replaces the tube on a weekly basis D. elevates the head of the bed after the feeding

D. elevates the head of the bed after the feeding

During a change of shift report, the night nurse indicates that a client cannot tolerate prescribed intermittent tube feedings. Which action should the receiving nurse take? A. suggest that an antiemetic be prescribed B. change the feeding schedule to omit nights C. request that the type of solution be changed D. gather more data from the night nurse about the technique used

D. gather more data from the night nurse about the technique used

After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube attached to negative pressure. Which would the nurse explain is the purpose of this tube? A. monitors the acidity of gastric secretions B. provides a route for liquid tube feedings when possible C. permits continuous decompression of the large intestine D. removes fluids and gas from the upper gastrointestinal tract

D. removes fluids and gas from the upper gastrointestinal tract

Three days after admission to the hospital for a cerebrovascular accident (CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action would the nurse take to evaluate whether the feeding is being absorbed? A. aspirate for a residual volume B. evaluate the intake in relation to the output C. instill air into the client's stomach while auscultating D. comparer the client's body weight with the baseline data

A. aspirate for a residual volume

The nurse is assisting with the end-of-life care of a client. Which activity is performed when the nurse views family as context? A. assess the resources available to the family B. meet the client's family's comfort and nutritional needs C. meet the client's comfort, hygiene, and nutritional needs D. determine the family's need for rest and their stage of coping

C. meet the client's comfort, hygiene, and nutritional needs

An older client states, "I've lived a good life. I don't want to die, but I accept it as a part of life." Which developmental task has the client achieved according to Erikson's psychosocial stages of development? A. identity B. integrity C. despair D. generativity

B. integrity

Which intervention by health care professionals helps prevent client medication errors according to the Leapfrog Group? A. scheduling regular follow-up visits B. prescribing a low dosage of medication C. using computer prescription order entry (CPOE) D. closely monitoring the client for 24 hours

C. using computer prescription order entry (CPOE)

The nurse administers an older adult client's medications via gastrostomy tube in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? SATA. A. absence of bowel sounds B. presence of abdominal distention C. residual capacity exceeding 300 mL D. positive guaiac test of abdominal contents E. seepage of feeding around tracheostomy

A, B, C, D, E

A family member of a dying client states, "My father is staring at an empty corner of the room talking to someone who is not there." Which suggestion by the nurse would provide the most comfort to the family member during this time? SATA. A. "Your father is unable to communicate in a normal manner." B. "You can reassure him this is part of the transition from life." C. "It is important that you provide him reassurance at this time." D. "This is a good time to encourage your father to verbalize his feelings." E. "This is a normal transition phase so it is best not to intervene in the process."

B, C, D

Which statement by the student nurse indicates the need for further education about medication administration? A. 'I should set up and prepare medications in distraction-free areas.' B. 'I should advise the certified medical assistant to administer intravenous medication.' C. 'I should be vigilant during the entire process of medication administration.' D. 'I should identify each client using at least two identifiers before administering medications.'

B. 'I should advise the certified medical assistant to administer intravenous medication.'

A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. Which action would the nurse take first? A. instill normal saline into the tube to maintain patency B. obtain an x-ray to verify that the tube is in the stomach C. auscultate the epigastric area while instilling 30 mL of air D. withdraw stomach contents to observe color and consistency

B. obtain an x-ray to verify that the tube is in the stomach

Which advice will the nurse give the client to avoid lipodystrophy when self-administering insulin therapy? A. exercise regularly B. rotate injection sites C. use the Z-track technique D. vigorously massage the injection site

B. rotate injection sites

Which statement by a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery indicates effective teaching? A. "TPN provides supplemental nutrition" B. "TPN provides short-term nutrition after surgery" C. "TPN provides total nutrition when gastrointestinal function is questionable" D. "TPN assists people who are unable to eat but have active gastrointestinal function"

C. "TPN provides total nutrition when gastrointestinal function is questionable"

Which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option? A. to receive palliative care, a provider must certify that you have 6 months or less to live B. the goal of palliative care is to humanize the end-of-life experience, allowing you to die with dignity C. the focus of palliative care is to enhance you and your family's quality of life despite your heart failure D. by making the choice to begin palliative care, you must no longer pursue life-extending or curative medical treatment

C. the focus of palliative care is to enhance you and your family's quality of life despite your heart failure

Which consideration would the nurse make when preparing to give a preschooler an intramuscular injection in the vastus lateralis site? A. the anterior third of the vastus lateralis is used to give an injection B. the vastus lateralis site is used to inject volumes greater than 10 mL C. the child should keep the knee straight to receive an injection at the vastus lateralis site D. the maximum recommended length of the needle insertion at the vastus lateralis site is 1 inch for preschoolers

D. the maximum recommended length of the needle insertion at the vastus lateralis site is 1 inch for preschoolers

If a toddler cannot be given or is not responding to oral chelating agents, parenteral medication must be used. Which is the priority nursing intervention to effectively prepare a child to cope with this painful treatment? A. rotating the injection sites and adding procaine to the chelating agent to ease the discomfort B. role playing with puppets dressed as hospital personnel to minimize the child's fear of unfamiliar adults C. explaining the rationale for the injections so the child does not view them as a punishment for bad behavior D. therapeutic play with a needless syringe and a doll before therapy is initiated and after the child receives each injection

D. therapeutic play with a needless syringe and a doll before therapy is initiated and after the child receives each injection